Rwanda Head of Environmental Health interview on impact of CHCs

Joseph photo

Interview with Dr. Joseph Katabarwa, Head of Environmental Health Desk Ministry of Health, RWANDA

Interviewer: Lisa Nash, Executive Director, Blue Planet Network,

6 May 2014

Lisa: How do you know Juliet and Anthony Waterkeyn of Africa AHEAD?

Joseph: Anthony was the first person to work with us as a consultant when we were developing our program. 2008.  He helped us design the program.  At that time, it was not in our thinking to introduce Community-Led Total Sanitation (CLTS) as part of our program.  We did not want to introduce CLTS because it depends on shaming and it is very coercive.  It was very important to us to build a program that depended on building local relationships and trust.  It was up to the community to decide what they wanted to do and to do it together.  Professionals and the government are there just to support the community.  Once you use coercive methods like CLTS, you destroy the trust and community friendship.  There can be no strong foundation to build on, and no future between you and the community.  We wanted the program to last a long time and to continue to be used by the community to speak of the importance of sanitation and hygiene, as well as help them create new income-generating ideas.  This would not have been possible with CLTS.

Lisa: What is your experience with the Community Health Club (CHC) model?

Joseph: Our program started in 2009.  In the beginning we actually wanted to harmonize all the hygiene education efforts used by the different NGOs and agencies to give them guidance and put in place a full policy that had not existed up until then.  We found out, however, that the education programs given at that time were ‘half cooked”.  It would not work to try to use them to teach the community.  That’s why we started our version of the CHC model, the Community Based Environmental Hygiene Promotion Programme (CBEHPP).  The many different hygiene education approaches were not reaching the community.  There was no sense of sustainability. The CBEHPP brought a sense of sustainability to the efforts.  It gave people the feeling that they themselves needed to solve their problems, not someone from the outside.  It also gave them the confidence that they could solve their own problems, because they solved problems together when they were part of CBEHPP.  They saw with their own eyes that it worked, and they wanted to do more.

CBEHPP directly uses the CHC model, which started in Zimbabwe.  We studied this model closely.  When we wanted to use this model in Rwanda, we made one small change.  Instead of calling them Community “Health” Clubs, we called them Community “Hygiene” Clubs.  “Health” is a very wide thing and there is so much within it like HIV, malaria, etc.  If you don’t give special attention to hygiene and sanitation, it could be consumed by other issues.  We wanted to ensure that sanitation and hygiene gained the ongoing attention of the community, because everything else in health depends on good sanitation and hygiene.  So we changed the name from “Health Clubs” to “Hygiene Clubs.”  But, otherwise, the programs were very similar.

Lisa: What were your first expectations for CBEHPP?

Joseph: What I thought first thing was that this program could be scaled up countrywide in a very short time because the program was so clear and focused.  We wanted to set up community hygiene executive committees in all the districts in a very short time.  A lack of funds, however, slowed us down.  So we started where we could and shared the best practices through the CBEHPPs.

Lisa, I must tell you one secret we came to know.  Whenever we started in a district and had funds, we told the community “We are ready to help you now.”  Typically, we heard from the community at first, “Are you going to provide us with water also?”  Some of the districts said to us, “If you don’t give us water to our community, we think your approach isn’t good.”  So we spent a lot of time trying to educate the communities in the district about the importance of getting sanitation and hygiene first.  Try to educate.  Eventually, the district would agree and start program.  In each District, there were 12 sectors.  We would start with 6 sectors.  Every sector came to realize that our approach was right, that sanitation and hygiene was important to do first so that any other effort afterwards could be sustainable.  The district mayors and communities we have worked with have learned the program very well and they tell others about it.  They attended the sessions they were supposed to attend and even did their homework!  They all said they got great knowledge about sanitation and hygiene and they would not be the same again.  They would be better and wanted to share this knowledge with everyone.

When the CBEHPP communities started the implementation phase, they decided to first construct toilets for those who were the poorest households, those who were not capable of doing it for themselves.  They would go and construct the toilets for them.  They also put up kitchen gardens for them.  Making sure that everyone in the community improved from this knowledge was important to them.  After sanitation, the communities started thinking about income-generation activities that they could do together.  They started contributing money so they could come up with income generation activities and make them happen.  This really brought the communities together and benefited everyone, especially the women.  Other NGO programs have studied the CBEHPP program.  They have learned from this program and adopted this approach also.

Lisa: What has been the impact of the CHC/CBEHPP model?

Joseph: Wherever we have introduced CBEHPP, the community is doing well.  Wherever we have not, they are demanding CBEHPP.  As I said, we have had people from US visit a CBEHPP program, e.g. World Vision.  They can tell you they were impressed.  Water Aid, from the UK, also can give testimony.

We think we have to put more effort to make CBEHPP happen all over our country.  It has become a very well developed program.  It makes people comfortable because it helps people understand they are free to talk about their hygiene problems and propose their own solutions.  Every community member is very free to contribute.  I like to say, “We used to go with “sticks” and beat the community members to build toilets.”  This was more like CLTS.  Now we give the “sticks”, or the power, to the community, not to beat each other, but to show us, and the community, the right way to go.

We need to go down to their level.  If we visit and they are seated on the mat, not on the chairs, we should be able to sit where they are sitting.  We don’t bring certain thinking that we are “above” and they are “low.”  Once they see that we give them respect, then they talk.  It’s the community who has the solution themselves.  They don’t know that they have it.  It’s for us to facilitate, to help them understand that they have the solutions.

I am very proud to see what the communities have accomplished for themselves.  They will change by themselves.  We need to be facilitators of that change.  We don’t say we will change the community.  We say that we will facilitate education and discussion so that the community can decide to change for themselves and how they will change. Once you realize this, it changes you.  You want to be an example of this to the community.  Stop telling them “do this, do this.”  No.  Give them time to discuss their ideas and challenges in a small group.  Everyone must have time to speak, every man, every woman, every child.  That is the way change happens.  Everyone must have ownership or it will not work.  It will not last.  The CBEHPPs do this.  They work.  They last.

Lisa: How does the CHC/CBEHPP model help women in particular?

Joseph: When we started, we didn’t want to say this program was for men or women.  We said it was for the community.  What came out in practice, however, was that the members of the CBEHPPs were totally women.  Women are the ones who benefit.  This is a very supportive environment.  The women are free to talk.  They talk to each other.  They learn confidence.  They learn how to share their problems.  They learn how to work together to make solutions.  This helps them in the program and in other places.  They don’t have many other places in which to experience this.  This also is very important for the benefit of the entire community to have more confident, stronger women.

In the second phase of the program, women work together to create income-generating opportunities.  Doing it with other women members.  There are men in the program, but just small numbers of men.  The beneficiaries are women and there are many benefits and income-generating ideas.  Kitchen gardens.  Soap making.  Food products.  I will send you other ideas as I think of them.  There are 20 topics in the program, most of them have to do with hygiene and sanitation.  When the group is done with these topics, they go to the second stage of program.  These are the income generation activities.  This is special about CHCs, about CBEHPPs.  They learn sanitation and hygiene in the first part, but then they continue to build upon what they learn and use it to do more.  In the income-generating activities, they get prepared, they collect money, they open a bank account in the name of the CBEHPP group.  Once the money saved is enough to start the income-generating project they have decided on together, we will try to help them.  We will help them come up with ideas about implementing their activities.  They work together to make this a real thing.  They learn together.

We are very happy with our CBHPP program, but we are planning to review the program.  There are several things that have come up that we want to add to the program.  We haven’t spoken about menstrual hygiene and this is very important.  This should be a part of the program.   We should help them understand good parenting skills and caring for children.   They need to discuss this together and decide together what they want to do to help their families.  We can add formal good leadership training.  We can help them discover and develop what it means to be a good leader.  If they can start discuss and negotiating together in the program, they can pick up these leadership skills naturally in a way so they always have them.  Women are much more confident about their own abilities and what they can do after participating in the program.  They feel supported.  They know they have done things together that prove they are capable of doing more.

Lisa: What do women who have participated in CHCs/CBEHPPs say?

Joseph: When we reach there, I don’t have words to express this.  They are so happy with the clubs, very happy, very happy when leaders visit them.  You can’t imagine.  They are ready to show you what they have done, people they have helped.  They are proud of their own work.  They come up with lots of ideas about what to do next.  This program gives them the time to think, provide their ideas and work with each other.  It changes everything for these women.

They say “it help us to open us more.” They feel comfortable.  The more they feel comfortable, they more they decide to do more things, and the more they accomplish.

Lisa: Do the women stay connected with the CHCs/CBEHPPs?

Joseph: This always is something they will be part of.  They just will do different activities when they are together.  Hygiene and sanitation have to be done quite continuously.  If they start with traditional pit latrines, they now have the capacity to build VIP latrines.  They are able to cement them for easy cleaning, and they understand how important that is.  Change comes slowly.  They first come to know the importance of VIP latrines and of cementing it.  Then they use the capacity they gain to do other things together.  Once they get the capacity, they use it, and they never stop.  We help them get the capacity for themselves.  It makes my heart proud.  It is the most exciting thing I can do.

Lisa: What about girls and CHCs/CBEHPPs?

Joseph: Sometimes I go to a village and just listen to how they are discussing.  Mothers bring their daughters to listen also and see what can be done.  What I can’t believe is to see their enthusiasm.  If someone has provided an idea, to see how are others helping to build up that idea.  Don’t expect people to speak harsh words to others in this program.  They have very good discussions together.  The girls come with their mothers.  Mothers pass knowledge to daughters and daughters help mothers to learn new ways.  The daughters become stronger and the mothers become prouder of their daughters and want to do more with them.

Lisa: What about students?

Joseph: I have demonstrated hand-washing on TV.  Afterwards, I have met a primary teacher who told me “My students saw you on TV washing your hands with soap.  They practice what you do.  They tell others,  “Have you forgotten what that man showed us on TV about hand-washing?””  Children are good in understanding and catching ideas.  They learn quickly and they spread the knowledge quickly.

I very much want to extend CBEHPPs to primary schools.  This is the time when children can learn and change their lives.  We have to develop training tools that are good for children.  Children must be given time to discuss at school, just like the communities. Children will bring experiences from their homes, discuss them at schools and make decisions.  I want to start with primary schools because primary schools are where the change starts.  But we need to keep the conversations going all throughout school.  Girls after primary school need to learn and discuss about menstrual health for example.  It is very important to keep them in school.  Our program, if we could expand it, could be a very good way to help them learn the best ways and share with each other to make change they practice forever.

We need capacity, the resources, to introduce this to schools for all ages of students.  We had a contract with the National University of Rwanda.  They were ready to help us to take CBEHPP to secondary schools and universities.  The university program was an initiative of the students at the university.  They worked very hard for it.  When they left university, however, the program stopped because the funds did not continue.  The students requested support from Minister of Health.  They were unsuccessful in getting the program into the budget, but they tried very hard and there was a lot of student support. In the university, there is a real spirit of loving to promote hygiene.  It is a national movement.  If I go there, and talk to president of the students, it is personal issue for them.  They believe in how important teaching about sanitation and hygiene is.  The students had several initiatives. One initiative was so practical and creative.  The initiative was to make a toilet cover which, when you want to use it, you don’t have to touch it.  You just step on something at the bottom of the toilet, and the cover comes up.  This toilet was designed to go together with a hand-washing initiative.  It was all about “Don’t touch!”

If you haven’t been exposed to this CBEHPP and CHC approach, you can’t know the goodness of it.  It is a very good model.  For instance, tin the beginning, there is a “train the trainer” session.  On the first day, beginning, you could see the people there were not “warm” to the idea, they were “cold.”  But from the second day, and especially on the third to the fifth day, it is fire!  Then they spread the fire.  It is wonderful!  In the end, they make their own planning for the training they will do when they go to the communities.  They are so excited that they go back home singing and happy!  It is so good to see this.

I always want to do this.